APPLICATION FOR DEATH CERTIFICATE APPLICANT INFORMATION-Print (bold letters) or type 1 Name of Applicant - First Name Middle Name/Initials Last / Surname 2 Address: Number, street, locality City/Town/Village Dt/Taluk/PO State Pin code 3 Telephone Number 4 Purpose for which certificate is to be used. 5 Relationship with deceased 6 Name of person receiving certificate(s), if different from applicant 7 Number of copies 8 Amount paid CERTIFICATE INFORMATION - Print (bold letters) or type 9 Name of the Deceased - First Name Middle Name/Initials Last/Surname 10 Name of the Father/Husband - First Name Middle Name/Initials Last/Surname 11 Age 12 Date of Death dd mm yyyy / / 13 Sex Female Male 14 Place of Death Hospital Other 15 Place of Death (Full address) City State Pin code 16 Name of the Hospital (If died in hospital) 17 Date of Registration (If available) 18 Registration Number (if available) DECLARATION I hereby state that the above information is true and request for the certificate. 19 Date: dd mm yyyy / / 20 Signature / Left thumb print DO NOT WRITE IN SPACE BELOW - FOR OFFICE USE ONLY 21 Name of SHO 22 Registration Number 23 Date of event: dd mm yyyy / / 24 Signature of the concerned case worker
